Homelessness remains a significant problem among veterans; more than 76,000 veterans are estimated to be homeless on any given night. Approximately twice that number experience homelessness yearly. Among the homeless, mean age at death ranges from 34 to 47 years. Cancer and heart disease were the leading causes of death in a homeless cohort age > 45. Veteran status was associated with a 1.7 increased odds of death. As more homeless veterans enter VA-supported housing, VA will need to provide for more of their medical and psychological care needs, which are likely to grow exponentially as they age. VA recognizes that care for homeless veterans and for those at the end of life (EOL - for the purposes of this proposal, having a health care provider-specified life expectancy of <1 year), are both top priorities, and i investing considerable resources in improving both. However, veterans who are both homeless and at EOL do not fit easily into the programs designed for either group, and not enough is known about their needs to plan for their care. The proposed research is designed to understand the scope of unmet need for palliative care among homeless veterans, and the barriers and facilitators to providing them excellent EOL care. The project's ultimate products will be a policy white paper and a program framework that can be tested and replicated across the country. This will enable the VA's Homeless Patient Aligned Care Teams (H-PACT) and Comprehensive EOL Care Initiative (CELCI) to better meet the structural and clinical needs of this population Objectives: (1) Describe current services for and perceived challenges of caring for homeless veterans at EOL, by surveying existing VA programs that care for homeless veterans and those at the EOL. (2) Develop a deep and broad understanding of the issues, barriers and facilitators to excellent EOL care for homeless veterans. (3) Define the key structural, clinical and policy elements required to reach out to and deliver excellent care to homeless veterans at EOL and generate a program design that can be tested and replicated across the nation. Methods: This is a mixed methods study. We will survey current VA programs for homeless veterans and VA CELCI programs to better understand what services are currently targeted for homeless veterans at EOL and regional and local medical center care variation. Based on survey findings, four sites that identify themselves as having significant homeless populations with EOL needs, in places where programs for homeless people who are at EOL may already exist, and which are, if possible, geographically dispersed, will be chosen to host two focus groups each to ascertain issues, barriers, and facilitators of EOL care. One focus group will consist of multi-disciplinary, front-line, medical, psychiatric, social work and substance abuse service deliverers who have primary contact with homeless veterans or who provide palliative care; the other will consist of middle managers who operationalize key directives, but have less direct veteran contact. In-depth interviews will be conducted with chronically ill homeless veterans and with Medical Center leadership at each site in order to understand their experiences with and perspectives on EOL care for homeless veterans. We will use a broad inductive approach to study rich contextual detail at the individual and group level at the four sites. A National Program Development Forum of stakeholders and policy makers, joined by one representative from each focus group, will be convened to draft a white paper addressing the policy and system redesign implications of what we have learned. After the results of that meeting are compiled, the forum will meet a second time to finalize the white paper and design and plan pilot testing of a program that can be replicated nationally. Anticipated Impact on Veterans Healthcare: At the conclusion of this study, VHA will have (1) comprehensive knowledge of existing approaches to the care of homeless veterans at EOL; (2) an understanding of the barriers and facilitators to providing excellent end-of-life (EOL) care for homeless veterans; and (3) a policy review and program framework for meeting their needs that can be tested and replicated across the nation.